Berita Harian Questions on 1Care Health Restructuring
1. What is the benefit/purpose of upgrading the GPs as gatekeeper, where everyone must choose/appointed GPs as their family doctor?
Most countries around the world are facing rising healthcare costs with greater and greater numbers of the citizens paying more out-of-pocket (OOP), i.e. paying for health or medical care with their own money. In Malaysia, this portion has reached around 40%, which is considered high. Insurance health schemes and other payment modes are still low in Malaysia, ranging from 7 to 14% only; with the rest coming from govt subsidised payments mainly from public service healthcare services.
Right now, many people who do not wish to wait for the subsidised health care provided by the public sector are opting for paying for private medical care usually by directly going to hospitals and private specialists for secondary or tertiary specialised care.
This is thought to be an expensive way for accessing healthcare. It is thought that by making the GPs or primary care doctors act as gate-keeper, this direct referral to special care can be better controlled and reduced, therefore also limiting the rise in healthcare costs and expenditure. But this has not been universally shown to be the case in most countries trying this model.
The reform that the MOH is choosing is modeled after the NHS of UK, where GPs must see the patient first before any referral to more specialised care, unless there are true emergencies. Also all citizens/residemts are mandated to be registered with one GP or primary care doctor, and they cannot change doctor easily or doctor-hop or doctor-shop without paying extra. This will help limit excessive and sometimes unneeded healthcare tests and costs.
We wonder whether this is feasible in Malaysia because most people have got used to the current system where everyone can choose as they wish, which doctor or public or private clinic or hospital to go to. This quite strict restriction of choice may not be acceptable to most people.
Can the govt or MOH guarantee quick and unfettered access to healthcare for the public with this new scheme? Would this perhaps make the private sector as bureaucratic or slow as both payment or registration will now be centrally or regionally controlled?
Would gate-keeping result in delay in seeing specialists or necessary surgery? Who would be responsible if there had been too much delay which result in bad or fatal outcomes? How would the MOH indemnify patients who might be harmed by such a change?
Would the public really want to have such a strict cut back on choice of service, doctors and specialists? Would there be too much control by the gate-keeping GP or MO who might be bothered by too much cost-containment or negative incentive payments or reimbursements?
There have been much criticism regarding the UK NHS, with many people questioning the wait times and slow services, but most accept this, because the costs of such an integrated service is borne by already-collected special taxes, controlled by regional health trusts. Also there is a fair bit of cost sharing and co-payment i.e. the patient still has to pay extra for each item of prescribed medicines etc, which can make many give up on some more expensive medicines or regular compliance with these medicines, esp. for chronic ailments such as hypertension, diabetes, heart disease, arthritis, etc.
2. What is MMA's role in realising the proposed 1Care should the government decide to embrace the new healthcare system?
The MMA (Malaysian Medical Association) is very concerned that such a drastic change without the necessary details to the implementation would be premature and would cause a lot of disarray in the health services available to the public.
The MMA fully supports the concept that every Malaysian be given guaranteed equitable and ready access to a reasonable basket of healthcare services, without cost being a factor to obstruct seeking of such care or services. Basic care is a human right which should be ensured.
However, whether this 1Care restructuring is the best method is right now, quite uncertain.
We need a clearer plan on how this method of integration and implementation of the healthcare services can be worked out seamlessly, with the practical and financial aspects fully understood by every stakeholder. The MMA is worried that there are still too many unknowns.
How much would this really cost the rakyat in terms of additional costs, either by additional taxes or payment of social health insurance (SHI) premiums--2, 3 or 5% or more? How much would employers have to pay? How do we pay for our dependents, at what quantum? Can the low-earning worker afford this new model of SHI?
Would civil servants be exempt or would the govt pay their portions so that this is fairer for all others who are paying? If this part is to be from the already allocated tax revenues, then why should the private sector pay extra for a collective and possibly more restrictive type of healthcare services?
Is our current health system so bad that we have to change this so drastically? If it ain't broke why change it? Is this another sort of GST-like extra tax, which would make every rakyat contribute some more, with little to show for the change?
How would doctors and the private healthcare sector be reimbursed/paid, since most of the 7000+ GP clinics around the country have been self-funded without govt incentives or assistance, and also that most if not all pay yearly income taxes already?
How can this be given the same payment schemes of public sector clinics (now numbering 800+) which are fully funded by government funds to date? Would there be unfair preferential allocations of patients or registrations or payments?
What about the private medical centres and hospitals which the government has been encouraging to expand these past 10-20 years? Would they suffer from over-restriction of referrals from the gatekeeping roles of primary care doctors? Who pays for specialised care?
How much of this integrated care would be consumed by administrative costs, which might be huge and wasteful.
Also there has been talk of only Family Medicine specialists (FMS) being the ones controlling all these primary care services, but these number only less than 200 and are all within the public sector!?
What then is the exact role of GPs, just an employed worker for the FMS? Would the GP role be subservient to these FMS, and what sort of quality assurance or qualifications are now to be made necessary for GPs to benefit more fully? Is this fair to the GPs, the rakyat?
3. Do you have any suggestion pertaining to 1Care? Btway, how many GPs or doctor do we have now. Is it enough to cover the Malaysian population (doctor patient ratio)?
The MMA agrees that we have a shortage of doctors in the country at this present moment in time, especially the poor distribution around the coutnry and the maldistribution to remote or rural communities especially in Sabah and Sarawak. Currently there is a doctor-population ratio of 1:900 (end 2010, doctor number 32,000), but the government wishes to quickly increase this to 1:400 by 2020, which means a total doctor number of around 85,000 to 90,000.
But the MMA has already expressed serious concerns that we are producing these doctors too quickly without adequate care as to the quality of doctors so graduated. We do not need so many doctors so quickly when our training facilities, hospitals cannot cope with their proper training and apprenticeship. We expect a severe glut or excess number of doctors who would do poorly and increase competition without the necessary increase in quality or safety of service for our rakyat!
While we support government efforts to streamline and improve the healthcare system in the country, we also ask that there be a more comprehensive approach to the restructuring plans.
We must have a detailed blueprint on every aspect of the newly planned scheme, so that all the stakeholders (doctors, other healthcare providers, hospitals, third party payers, insurers from every sector) can comprehensively debate and improve the potential problems, which are bound to arise.
Powerpoint flow-charts which are impermanent and freely modifiable, without the necessary details or minutiae are clearly not enough!
Until this detailed document is available, it is too premature to accept this plan without careful thoughts, and we believe that this 1Care reform plan may be very difficult to implement. This may lead to severe breakdown of the services which would face unsure or unfamiliar new grounds.
With additional co-payments from the rakyat, the MMA wonders whether such a change would really improve the system or merely costs more without the attendant benefits expected by our more discerning and knowledgeable citizens.
In short, we urge the government to ready itself with a more comprehensive plan which should be written down in detail, so that all these uncertainties can be addressed and overcome, so as to lessen the unintended consequences of this restructured 1Care health plan.
Dr David KL Quek